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International Journal of Caring Sciences September - December 2013 Vol 6 Issue 3
SPECIAL
PAPER
300
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Synthesizing Knowledge about Nursing Shift Handovers: Overview and
Reflections from Evidence-Based Literature
Efstratios Athanasakis, BSc, RN
Graduate Nursing Faculty, Alexander Technological Educational Institute of Thessaloniki, Greece
Correspondence: Athanasakis Efstratios. Antifilipi, 64001, Kavala, Greece.
e-mail: [email protected]
Abstract
Background: Nursing shift handovers consider to be a pattern of communication that is applied in everyday
clinical nursing practice, in order to be fulfilled the goals of organization, continuity, consistency and safety of
care that nurses provide to patients.
Aim: The aim of this review was the evaluation of the body of current research evidence examined issues
concerning shift handovers in nursing.
Methodology: A combination of various search terms: nurses, nursing, shift handovers and bedside handovers
were used to search the Pubmed database. Also, a manual search contributed to the detection of more articles.
For the introduction of an article in the existing review, specific inclusion criteria were set.
Results: A total of 19 original research articles were included. A table of shift handover models and another one
of the basic characteristics of the research articles are presented. Analysis of the research findings provided three
major themes related to the aim of the review, as follows: ′handovers’ components′, ′change type of handover′
and ′handovers’ standardization′. A large part of the research literature looked at the exploration of the elements
that handovers are composed of.
Conclusions: This review highlighted evidence-based literature of fundamental information for nursing shift
handovers. Effective communication practices among nurses entail effective handovers, effective patient care
quality and patient safety maintenance. Nursing shift handovers are a multifaceted activity, which needs deeply
understanding. Further knowledge development of handovers is required.
Κeywords: nurses, nursing, shift handovers, bedside handovers.
Introduction
The patients’ care organization, continuity,
consistency and safety are essential functions in
the field of clinical nursing practice. The aspects
of nursing care organization can be easily
covered by information exchange among the
nursing staff members between the nursing
shifts (Kerr, 2002, McMurray et al, 2010). Also,
except from the fact that information should be
effectively transferred from the offgoing to the
oncoming nurses, even the attention of them or
the communication with other members of the
multidisciplinary team, such as the doctors, is
equally important (Chaboyer et al, 2009).
As the World Health Organization (WHO)
contended, the factor of miscommunication may
cause patient harm (WHO, 2007). Information
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about patients’ care officially occurs in written
nursing records or in oral reports called (shift)
handovers and unofficially with verbal way
during the activities of the nursing routine
(Payne et al, 2000, Meissner et al, 2007, Johnson
et al, 2012a). In the context of delivery accuracy
in patient care, documentation can be used as a
way of communication. The message "Do it.
Document it." was used by authors, for the
encouragement of nurses to the direction of a
change to written handovers (Tucker et al,
2009).
Nursing shift handovers are a regular feature of
the everyday clinical nursing practice, a ritual
for the nursing team which happens every time a
shift change is performed (Evans et al, 2008,
Scovell, 2010).
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301
As Australian Medical Association (AMA)
defined, the "clinical handover is the transfer of
professional responsibility and accountability for
some or all aspects of patient care or group of
patients to another person or professional group
on a temporary or permanent basis" (AMA,
2006).
place in a room/office/nurses’ station away from
the bedside (Johnson et al, 2012a). However, in
recent years in nursing literature are identified
various studies that have focused on the
exploration of bedside handovers’ issues
(Philpin, 2006, Chaboyer et al, 2009, Chaboyer
et al, 2010, McMurray et al, 2010).
The UK Nursing and Midwifery Council
(NMC), states that nursing care record-keeping
and information sharing by nurses in the
duration of a shift are more integral parts of the
practice rather than optional (NMC, 2009). In
addition, the UK Royal College of Nurses
(RCN), in a nine-part series described principles
of nursing practice which entails a special
reference in the effective communication (Casey
& Wallis, 2011).
Aim
It cannot be neglected the fact that handovers in
patient care are not part of the official education
programs in nursing schools. So, nurses do not
undergo any regular and particular training at
undergraduate level and nurses learn the way of
giving handovers within the wards’ culture.
Although the handovers’ value for the nursing
practice, as has been argued by another author,
remain still "one of the most important rituals of
the nursing shift" and sometimes probably not
receive the proper attention from nurses
(Scovell, 2010).
During shift handovers is discussed a set of tasks
that should be carried out in the duration of the
coming shift, like the collection of specimens,
the record of observations, wound swabs and
tasks from other health care professionals that
nurses should be informed that had been done
(Randell et al, 2011). For the description of
nursing tasks, the documents that are usually
conclude are admission, referral, discharge
documents, progress notes, medication charts,
observations charts, nursing care plans and
documents between health disciplines (Sexton et
al, 2004, Tucker et al, 2009).
Nursing shift handovers present variation from
ward to ward and among hospital settings. Table
1, outlines a synthesis of general information of
the handover models and their characteristics.
Regarding their types, researchers reported that
handovers can be verbal, tape recorded, at the
bedside and written (Sexton et al, 2004).
Nursing shift handovers almost always take
www.internationaljournalofcaringsciences.org
The aim of this review was the evaluation of the
body of current research evidence examined
issues concerning shift handovers in nursing.
Methodology
A search of the relevant literature has been
conducted in Pubmed electronic database, using
the following search terms: nurses, nursing, shift
handovers and bedside handovers. Studies that
were taken into account were having the
following inclusion criteria: were original
research articles (primary or secondary analysis
research studies with qualitative or quantitative
or mixed design), published in English, between
January 2000 and December 2012, with free full
text provision, clear methodological design,
using in the study sample apart from nurses
(working mainly in hospital wards/settings),
patients or doctors. Besides the above search,
another one (manual) took place. A total of 28
articles identified as potentially relevant, n=20
from the Pubmed search and n=5 from the
manual search. After assessing of the retrieved
titles and abstracts, were excluded: n=3 articles
because they were irrelevant and n=3 articles
with no full text provision.
Findings
Nineteen research studies were found to meet
the inclusion criteria. A summary of the basic
characteristics of the research articles is shown
in
Table 2. The studies originated from Australia
(n=10), UK (n=5), Sweden (n=1), Switzerland
(n=1), Mauritius (n=1) and one conducted in 10
European countries. Elements of the nursing
handovers subthemes were investigated and
findings are presented according to their
relevancy. Analysis of the studies’ findings
provided three major themes related to the aim
of the review, as follows: ′handovers’
components′, ′change type of handover′ and
′handovers’ standardization′.
International Journal of Caring Sciences September - December 2013 Vol 6 Issue 3
Theme 1: Handovers’ components
A number of studies were mentioned to one or
more handovers’ components. This theme is
divided into six subcategories: location,
participation,
patterns/structure,
content,
temporal
characteristics
and
ancillary
documents-nursing records. Nursing shift
handovers’ characteristics and their morphology
across the countries are key factors for the
enhancing of a wider comprehension around
fundamental handovers’ points.
Location
Location of handovers varied depending on the
needs of each specialty and impacted on what
information was transferred. Namely, in a
medical/surgical unit, handovers were at the
bedside; avoid discussing patient diagnosis that
moment. Contrarily, in mental health specialties,
handovers were given in a room where access to
patients was not allowed (Johnson et al,
2012a).Interruptions during handovers play
important role in the handovers’ performance.
Meeting spaces properly designated for the
interruptions’ reduction during handovers.
When patients were transferred across different
wards, it was more likely that handovers were
impaired, on account of communication failure
between bedside nurses. Handover process
happened in two stages: firstly in a closed room
(private space) and then at the bedside, the
corridor or the staff station (public space).
Handovers in private spaces prioritise
organizational and biomedical discourses
(lacking nurses’ perspectives on care). Besides,
handovers in public space facilitate a partnership
model in medication communication (Liu et al,
2012).
When handovers took place in the charge
nurses’ office, the possibility of any interruption
occurrence was low. Bedside handovers are
more prone to any type of interruptions. Aiming
at nurses’ conscientious attendance during
handovers, it is necessary that interruptions
should be lacked (Evans et al, 2008). To this
direction, before handovers start, nurses asked
the patients if their needs were covered, along
with the explaining that handovers will start
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302
soon, so that to limit interruptions (Chaboyer et
al, 2010).
As it is documented, bedside handovers have
multifaceted benefits. They bring nursing team
together, promote patients’ safety scan (call bell
in reach, suction or oxygen working properly,
etc) and medication review, promote a patientcentred dimension of handovers, patients gave
key essential information to nurses and provide
to them the opportunity to participate actively in
the process of their care or to their relatives the
possibility to clarify aspects of patients’ care
(Chaboyer et al, 2009, Chaboyer et al, 2010,
Randell et al, 2011).
Bedside handovers offer directness. That is,
when a theme or a statement of patient care was
unclear to the oncoming nurse, they could ask
their offgoing colleagues to clarify or fix this
matter immediately. In the same study a major
disadvantage identified: patients perhaps hesitate
to participate in handovers and this is due to the
use of medical jargon or the presence of many
nurses around the bed (Chaboyer et al, 2009).
Participation
Traditionally, only nurses participate in
handovers (Johnson et al, 2012a). Especially, for
the bedside handovers, the team leader of the
outgoing shift and all three team members of the
oncoming shift were present (Chaboyer et al,
2010). The contribution of nurse coordinator had
been emphasized in a recent paper. In handovers
participated all oncoming nurses and the
offgoing nurse coordinator. The nurse
coordinator had a role of mediator
communication with a special focus on patients’
needs (Liu et al, 2012).
In intensive therapy unit (ITU), when patients
were awake and conscious, nurses tended to
implicate the patient to the bedside handover
process on purpose, usually when a positive
statement for the patient progress was expected
to heard by nurse (Philpin, 2006). In a study
conducted in multiple open wards, family
members were permitted to stay in and go out in
accordance to patients’ decision, prior handover
process. The patients and their family members
were encouraged to ask any questions at the end
of handover (Chaboyer et al, 2010).
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303
Table 1. Synthesis of evidence about handovers’ models and characteristics.
Characteristics
Models of
handover
Content
Location
Verbal
(face-toface)
Use of jargon and biomedical vocabulary to discuss patients’
issues and plan the activities of nursing care. Give the chance for
nurses’ query expression about patients’ situation. Can concern
handovers between a team or can be nurse-to-nurse.
Usually takes place in a
designated
location
(meeting room, nurses’
station).
Non-verbal
Contains movements like the raised eyebrows and head shaking.
Usually takes place in the
patient bedside.
Verbal
(face-toface)
Use of jargon and biomedical vocabulary to discuss patients’
issues and plan the activities of nursing care. Give the chance for
nurses’ query expression about patients’ situation. Can concern
handovers between a team or can be nurse-to-nurse.
Usually takes place in a
designated
location
(meeting room, nurses’
station).
Tape
recorded
Are less time consuming with limited interruptions. It is possible
that nurses’ queries about the patients’ information will remain
unanswered. The tape can be stopped at anytime the nurse wants
and starts again at a later time.
No information found.
Written
(note-taking
style)
Use of various textual materials to describe patient progress,
conditions and the serious events of the shift that passed. The
oncoming nurse access existing documentation to ascertain
essential information.
Bedside
Gives opportunity to nursing students for teaching and to patients
for discussion care issues. Can be used either verbal or non-verbal
communication ways.
Needs attention: a) when jargon is used by caregivers, the patients
probably feel anxiety and b) when the staff has little awareness.
Patterns/Structure
Research’s findings as described in the study of
Kerr (2002), four types of handover are
summarized according to the function's main
attributes (informational, social, organizational,
educational) and are distinguished in three phases
(prehandover,
intershift
meeting
phase,
posthandover). Further, Bruce & Suserud (2005)
explored the experiences of six emergency nurses
relevant with the handover process.
Analysis of the study’s results showed four
handovers types: the pre-hospital reporting
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No information found.
Takes place in the patient
bedside.
(usually through telephone, critical patient
condition,
structured
information-brief
communication), the symbolic handover (the
emergency nurse forms an impression of
patients’ care needs), the ideal handover (make a
holistic picture of the patient to inform his/her
triage function) and the non-ideal handover
(difficulties in forming holistic picture of
patient). In some handovers’ cases observed, it
seemed that confusion were predominant when a
specific structure for handovers was missing
(Sexton et al, 2004).
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304
Table 2. Summary of the basic characteristics of the research articles.
Author &
country
Payne et al.
(2000)
UK
Objective
The exploration of the
role of nursing
interaction within the
context of handovers
and the identification of
clinical discourses by
staff for the
determination of the
care delivery.
Kerr (2002)
UK
The description of
practices and activities
of handover,
classification and
characterization of
functions of handover
and identification of
some effectiveness and
problems criteria.
Sexton et al. The address of the
(2004)
content of nursing
Australia
handover when
compared with formal
documentation sources.
Method, data collection
& analysis
Qualitative design
Grounded theory
analysis
Ethnographic approach
foe data collection: nonparticipant observation,
semi-structured
interviews, audio-taped
of handovers and
documentary data
Mixed-method:
Interviews
Cross-sectional,
comparative and case
study design
Semi-structured
observation
Sample & setting
Major findings
23 handovers
34 RN
Informal
interactions between
nurses (146 hours)
5 wards of an acute
elderly care unit of a
district general
hospital
Handovers were formulaic,
partial, cryptic, given at
high speed, used
abbreviations and jargon,
required socialized
knowledge to interpret,
prioritized biomedical
accounts and emphasized
physical aspects of care.
20 handovers from
pediatric wards
from 12 in-patient
wards of a pediatric
hospital
Handovers practices are
distributed over a variety
of factors and their
effectiveness is depending
on demands and tensions.
Use of qualitative data
analysis programme
23 handovers from a
general medical
ward of a hospital
Almost 85% of the
information discussed
could be located within
existing ward
documentation structures,
9.5% discussed was not
relevant to ongoing patent
care and 5.9% the inverse.
The handover process
could be many sided, more
dependent on patients’
problems and there were
difficulties to place patient
groups at the correct care
level.
The new system evaluation
was positive concerning
patient and staff
satisfaction.
Bruce
& Suserud
(2005)
Sweden
The exploration of
nurses’ experiences
receiving patients who
were brought into
hospital.
Qualitative descriptive
design
Interviews
6 nurses working in
ambulatory and
emergency hospital
services
Kassean &
Jagoo
(2005)
Mauritius
The address of the
implement of a new
system of bedside
handover.
Philpin
(2006)
UK
The illustration of ways
in which insights from
anthropology may be
used to explore
information
transmission.
Case study
Adaption of planned
change model
Semi-structured
interviews
Qualitative design
Participant observation
Ethnographic design
Interviews
10 non-participant
observation
handovers
40 patients from a
gynecological ward
15 nurses from ITU
and documentary
material
Quantitative design
Descriptive and nonexperimental crosssectional survey
Questionnaires
21 nurses, 42
paramedics and 17
doctors from 4
ambulance and 1
emergency service
Jenkin et al. The identification of the
(2007)
current process of
UK
information transfer
between the staff during
patient handover.
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Both verbal and written
handover reports are
visual and/or audible
symbolic representation,
confirmations and
validations of nursing care
provided.
Emergency staff needs to
appreciate that a lack of
active listening skills can
lead to frustration for
ambulance. Handovers for
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Meissner et
al. (2007)
10
European
countries
The exploration of
nurses’ perceptions of
the shift handovers and
the possible reasons for
reported dissatisfaction.
Quantitative design
Cross-sectional design
Questionnaires
Secondary data analysis
22902 nurses from
hospitals
Evans et al.
(2008)
Australia
The analysis of field
notes taking during a
series of nursing
change-of-shift
handovers.
Psychoanalytic case
study
14 handovers from
a medical ward of a
metropolitan
teaching hospital
Chaboyer et
al. (2009)
Australia
The description of the
implementation of
bedside handover in
nursing.
Quality improvement
project
27 nurses from 3
wards of a regional
public hospital
Yee et al.
(2009)
Australia
The development of a
standardized operating
protocol and minimum
dataset to improve shiftto-shift clinical
handover.
Pilot study
Triangulation of
qualitative data sources
(handover notes, field
observations, focus
groups)
Chaboyer et
al. (2010)
Australia
The description of the
structures, processes
and perceptions of
outcomes of bedside
handover in nursing.
Mixed-method:
Descriptive case study
Semi-structured
observation and indepth interviews
Content analysis
120 observations
sessions
112 interviews (60
nurses, 60 doctors)
More than 1000
individual patient
handovers (51
nurses, 61 doctors)
from 6 wards
532 handovers
34 nurses from 6
wards in 2 hospitals
McMurray
et al. (2010)
Australia
The identification of
factors influencing
change in hospitals that
moved from taped and
verbal to bedside
nursing handover.
The description of
current practices for the
conduct of shift
handovers and to use
this as a basis for
Qualitative study
Semi-structured
observations
In-depth interviews
Thematic analysis
532 handovers
34 nurses from 6
wards in 2 hospitals
Qualitative
A multi-site case design
Observations
Interviews
15 medical and 33
nursing shift
handovers across
three case sites from
wards of a general
Randell et
al. (2011)
UK
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305
critically ill patients should
be delivered with essential
information given
immediately and provision
of further details when the
initial treatment has been
undertaken.
The proportion of nurses
dissatisfied with shift
handovers varies
considerably in Europe,
attributing the reason of it,
to work organizational
aspects accounts.
The ritualized handover,
as identified in the nurses’
speech, becomes on way
that anxiety shape, in a
discursive way, the
practice of the nurse. In
this way the ritual
handover is a discourse of
anxiety.
Bedside handovers
improve safety, efficiency,
teamwork and the level of
support from senior
members.
The standardized protocol:
"HAND ME AN
ISOBAR", supports
flexible adaption to local
circumstances.
At bedside handovers
nurses receive report on
only their assigned
patients.
Nurses pose positive
thought for bedside
handover, but this may not
be accurate.
The change is more likely
to be successful when it is
part of a broader initiative
such as quality
improvement strategy.
Technology should focus
on supporting rather than
replacing the verbal shift
handovers and allows the
gathering of the required
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Bradley &
Mott (2012)
Australia
considering the role that
technology could play in
supporting handover.
The introduction of
bedside handovers.
Johnson et
al. (2012a)
Australia
The development of a
minimum data set for
electronic nursing
handover.
Johnson et
al. (2012b)
Australia
The exploration of
clinical handovers in
nursing and the
provision of an
appropriate structure to
support an electronic
tool.
The examination of
forms communication
and power relations
surrounding medication
communication during
handover.
Liu et al.
(2012)
Australia
306
hospital
information.
Mixed-method:
Quantitative (quasiexperimental) and
qualitative
(ethnographic) design
Questionnaire and
interviews
Qualitative study
Observational design
Content analysis
48 RN from 3 rural
hospitals
Qualitative design
Thematic and content
analysis
81 transcripts of
clinical handovers
from mainly
medical and surgical
patients
from multiple
settings
76 nurses and 27
patients from 2
medical wards of a
teaching hospital
Bedside handover
approach is significantly
less time consuming than
the closed door approach.
Reduction of frequency of
incidents under the
bedside handover process.
The NH-MDS can be a
guide for patients’
condition, care and useful
for clinical nurses and
educators.
ICCCO is a type of
structure that covers the
required patient
information during the
handovers.
195 patient
handovers
from multiple
hospital settings
Qualitative
Critical ethnographic
design
Participant observation,
field interviews, videorecording and video
reflexive focus groups
Handovers involving
patients in the public
spaces at bedside
facilitated a partnership
model in medication
communication. Nurses
avoid talking sensitive
themes at the bedside.
Mayor et al. The exploration of
Mixed methods:
Nurse unit
Unit type affected
(2012)
variations in handover
Structured interviews
managers of 80 care communication content,
Switzerland duration and
Content analysis
units in 18 hospitals have higher duration of
communication in
Quantitative analysis
handover per patient and
nursing units.
functions of handover.
NH-MDS: Nursing Handover-Minimum Data Set, ICCCO: Identification of the patient and clinical risks,
Clinical history/presentation, Clinical status, Care plan and Outcomes/goals of care, RN: Registered Nurses,
ITU: Intensive Therapy Unit.
Ιn a quantitative study (cross-sectional) have
been examined the transfer of information from
ambulance staff to emergency department staff.
The patient report form was a document type of
written handovers, although study sample n=80
(nurses, paramedics, doctors), had both positive
and negative views about its value and efficacy.
Based on the findings of the study, a possible
framework for patient handover in emergency
department was developed by authors (Jenkin et
al, 2007).
In the same study, nurses working in emergency
department settings, thought that handovers for
critically ill patients should be delivered firstly
(important information) when the ambulance
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arrived at the hospital and secondly (further
information), after the initial treatment has been
undertaken. Similarly, repetition of handovers
happened: in category A patients (from triage),
more commonly to doctors, at anytime of the day
and more frequently in the resuscitation room. In
a patient handover, the reason for attendance was
considered as the most essential information by
doctors and nurses (Jenkin et al, 2007).
Another patterns of nursing shift handovers in an
emergency assessment unit and a pediatric
surgical ward include the begin of handover with
patient that outgoing nurse was with when the
oncoming nurses were ready to receive handover
or would be ordered by bed number and the
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handed over for all patients (in staff room) from
the outgoing to the oncoming nurse, since the
second one was responsible for multiple patients
(Randell et al, 2011).
An ethnographic study of the examination of
transmission of information between nurses in an
ITU concluded a variety of written methods to
communicate during handovers, like the
observation chart, the use of different colour pen
in writing, paper towels and nursing notes. The
combination of written methods with verbal and
non-verbal methods represents a way of
communication in the demanding environment of
the ITU (Philpin, 2006).
Content
Verbal handovers were delivered in "passive
voice", were partial, cryptic and characterized by
use of medical jargon, abbreviations and initials,
e.g. MI instead of myocardial infarction, when
applied by nurses. But, it was not the same when
handovers were attended by newly qualified
nurses or nursing students (Payne et al, 2000).
Concerning patient sensitive information
management, this was discussed away from the
bedside, e.g. outside the room, was written on the
handover sheet or can be discussed between the
staff members after the integration of the
procedure (Kerr, 2002, Chaboyer et al, 2009,
Chaboyer et al, 2010).
When nurses were handed over verbally, they
used jargon or slang to describe events happened
relevant with the patient situation. When nonverbal communication ways were used, they
were concluded actions as raised eyebrows, head
shaking and "clucks" of concern (Philpin, 2006).
Another example of non-verbal communication
contained non-verbal gestures by the offgoing
nurse coordinator, targeting to tone down
complaints from the medical staff (Liu et al,
2012).
Basically, information transmitted on handovers
focused on what happened in the previous shift,
the information nurses should know for the
current shift and the information that needed to
be transferred to the nurse of the next shift
(Randell et al, 2011). Another central handovers’
topic was the patients’ medical state (Mayor et al,
2012). However, nurses had difficulties when
patients had not been labeled with a "crash
status" and feel uncertain on how to act when
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307
resuscitation or not information were missing and
the patient suddenly die (Payne et al, 2000). For
this reason, handovers were a two-way
communication process, where the oncoming
nurses had the chance to search for further
information and clarification for patients’ issues,
if information was interspersed or unspecific
(Randell et al, 2011).
Nurses throughout the handover process used
stereotyped comments for the description of
patients’ situation or general statements for
summarizing handovers’ information. Here are
some examples of phrases: "He’s been a very
naughty boy. He’s refused to eat and drink
today.", "She’s gorgeous.", "She doesn’t look
good this afternoon.". Authors pointed out that
stereotyping in handovers offers to the nurses of
the oncoming shift a "picture" of the patients in
the ward, that nurse would take care of regardless
if they have met the patients in a previous shift
(Evans et al, 2008, Randell et al, 2011).
Sexton et al. coded handovers’ themes into
categories: charting, non-charting (relevant,
irrelevant), bed and ward management. From the
amount of information discussed at handovers,
84.6% of them could be incorporated in
documents and the rest percentage could not.
While, 9.5% of information characterized as
irrelevant to ongoing patient and 5.9% of the
handover content was related to ongoing patient
care or ward management issues that could not be
reported in ward documentation (Sexton et al,
2004).
In a major survey entitled Nurses’ Early Exit
Study (NEXT) are presented data pertaining
nurses’ perceptions of shift handovers. Research
data were collected from a large sample of nurses
coming from 10 European countries. The study’s
findings articulated that nurses (from 7 countries)
considered the organizational nature factor: "too
many disturbances", as the principal reason for
nurses’ dissatisfaction with handovers. The
conclusions drawn by authors emphasized the
lack of research evidence about handovers’
central aspects (why, where, how, whom)
(Meissner et al, 2007).
In a case study, used a psychoanalytic theory
approach for the examination of how anxiety
discourses might affect the organization of
nursing practice and particularly the handovers.
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The authors mentioned that a ritualized handover
characterized by unwritten laws (prohibitions).
These comprised no arguments permission,
occasionally opinion contradiction or difference
expression, avoidance to mention patients’ name
during their allocations, avoidance of any
expression of pleasure or displeasure and of any
preference to specific patient. The principal
finding was that anxiety appears (in a discursive
way), when a ritualized handover was performed
by nurses. Thus, nurses to avoid overwhelming
by anxiety tried to alleviate this feeling and met
the needs of the clinical practice (Evans et al,
2008).
handovers’ structure in various settings. Authors
found five major categories of information
discussed at its duration. These include
identification of the patient, clinical history,
clinical status (signs, symptoms), care plan (tests
or diagnostic procedures, self-caring themes) and
outcomes of care (goals of care for that shift
passed, discharge planning). All the above factors
are represented with the acronym ICCCO
(Johnson et al, 2012b). Categories of content
handovers’ features may not be mentioned in
every handover, but the majority of them were
discussed at every handover (Evans et al, 2008,
Johnson et al, 2012a).
Ritualistic handovers’ features were an inclusive
prereport discussion, cross-sectional reports,
stereotyping of patients, a strict numerical order
to the report, which ended with a concluding
remark, the handover never being cancelled, a
conscientious approach to the handover and bans
on both in-person interruptions and the presence
of those not involved in the handover (Evans et
al, 2008).
Temporal characteristics
Over the years, handovers have received many
characterizations concerning their duration. Some
authors characterized handovers as "high speed"
(when handovers for 20-30 patients described in
20 minutes), "less time consuming" (when took
place in the bedside than the closed door
approach) and "thorough procedure" lasting 15
minutes (Payne et al, 2000, Philpin, 2006,
Bradley & Mott, 2012).
Handovers’ content may be characterized of high
levels of uncertainty. If this is the case, then the
variety of topics discussed during handover was
lessened (Mayor et al, 2012). However,
handovers are a kind of problem solving function
that help nurses focused on every particular
factor around the patient state, like treatment
modifications, falls, behavior, feeding and other
(Randell et al, 2011).
Apart from having to perform a range of a variety
of nursing interventions, handovers could be an
opportunity for the nurses’ emotional expression
and socialization. Nurses in one study were
expressing their emotional support to each other
by sharing stories and experiences or consider
themselves as "natural" when socializing (Kerr,
2002). Examples from the nurses’ descriptions
indicate that handovers could be a motivation for
sharing experiences or complaints (Randell et al,
2011). Sharing emotions identified as the top
function (64% of the units included), in a recent
published study exploring uncertainty in nursing
practice. Other functions have to do with team
coordination (46%), group-sense making (31%)
and educational (23%) (Mayor et al, 2012).
Another study conducted by the same authors
and published the same year, explored clinical
www.internationaljournalofcaringsciences.org
In other studies, handovers’ duration was
detected at 10-15 minutes spent for the group
handover or at 15-60 minutes (Payne et al, 2000,
Liu et al, 2012). In an emergency assessment unit
nursing handovers had overall duration of 30
minutes, with approximately 2 minutes
discussion/patient (Randell et al, 2011). In other
settings (medical, surgical, medical-surgical,
rehabilitation) each bedside handover took (on
average) just over a minute (Chaboyer et al,
2010).
Researchers observed 23 handovers by time of
the day in one general medical ward. Handovers
frequency was 3 times/24 hours (07:00 am, 14:30
pm, 22:45 pm). For example, at 07:00 am there
were observed 7 handovers, with mean length of
18 minutes and their range between 15-22
minutes. However, the other handovers
(afternoon and night) had more mean length (39
and 33 minutes respectively) (Sexton et al, 2004).
Other studies advocated that handovers’
frequency was 3 times/24 hours (07:00 am, 13:30
pm, 21:00 pm) or usually one time in the
morning and one in the afternoon (Payne et al,
2000, Randell et al, 2011).
International Journal of Caring Sciences September - December 2013 Vol 6 Issue 3
Variations in nursing handovers’ duration and
communication had been examined in a recently
published study. The handovers topics and their
duration per patient were related to taskcontingent factors. Specifically, when the factor
of uncertainty was evident in unit types where
care was continuous or intensive, the mean
handover duration per patient was increased (3.7
and 4.4 seconds respectively) than other unit
types (non-acute and standard care, <1.5
seconds/patient) (Mayor et al, 2012).
Decreased length of bedside handovers (in
relation with the office handovers), offered to
nurses more satisfaction. Researchers observed
that in the pre-implementation phase (office
handovers) the mean total time taken to handover
per patient across all sites was 0.44 hours. On the
other hand, after the implementation of bedside
handovers, it was evident that the average time
was 0.22 hours (Bradley & Mott, 2012).
Ancillary documents-nursing records
It was more likely that nurses kept records before
handover or after the end of the shift (Kerr,
2002). But nurses from ITU were taking nursing
notes at the end of each shift, when "there was a
lull in the unit’s activity". Although notes were
taken in the observation chart, more notes by
nurses completed the care that they previously
provided (Philpin, 2006). Moreover, nurses used
three levels’ of nursing records, two formal
(Kardex, computerized care plans) and one semiformal document (ward diary).
In order to maintain every patient detail, every
nurse used to keep additionally personal nursing
records or combined them with electronic
handover sheets (during the bedside round)
(Payne et al, 2000, McMurray et al, 2010). A preprinted sheet developed from spreadsheets or
work processing documents was use in verbal
face to face communication (Johnson et al,
2012a). Personal notes taken by nurses during
handover process are more likely to have a role
of a "safety device" for them (Kerr, 2002).
However, the fact of having to do a lot of actions
described in their personal records (in an
informal way), correlated with the feeling of fear
of penalties (Payne et al, 2000).
In another study, bed list, patient name and
diagnosis were used to make notes during the
handovers, whereas no formal sources of patient
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309
information were used. Keeping up to date every
detail of the organization of patient care is a
challenge. As it is known, nursing shifts are
characterized by heavy workload and plus the
nursing staff shortage, there is minimum time for
updating care plans’ information (Sexton et al,
2004). Fixed items that were frequently included
in handover process are the bed number, care
plan, clinical alerts, clinical history, clinical
status, current observations, fluid input and
output, outcome of care, patient identification,
procedures undertaken, reason for admission and
tasks to be completed (Johnson et al, 2012a).
Nurses had an individual coding system using
nursing records known as "scarps", which were
kept in nurses’ pockets contained valuable
information for the organization of nursing care
(Payne et al, 2000). Paper towels were used to
take notes briefly in themes like points to raise on
the ward or the order of medications. Author
attached the reason of the paper towels use in the
differentiation of the important from the
permanent
information
(Philpin,
2006).
Moreover, during bedside handovers, a
computer-generated handover sheet which
included patients’ name on the ward. Nearby the
bedside
components
of
health
record
(observation record, medication record, fluid
balance sheet and risk assessment forms) were
available (Chaboyer et al, 2010). Verbal face to
face communication using a pre-printed sheet
developed from spreadsheets or work processing
documents (Johnson et al, 2012a).
Theme 2: Change type of handover
Four studies analyzed the change process, from a
handover type to another one. In two studies was
applied the Lewin’s 3-stage model for the change
of handovers’ type (Kassean & Jagoo, 2005,
Chaboyer et al, 2009). The fist one is a case study
from Mauritius which mentioned to the change
from traditional to bedside handover. The model
of change comprised from 3 planned steps:
unfreezing, moving and refreezing. The change
evaluation showed that the new method of
handovers was working, but authors mentioned
that monitoring will be ongoing with evaluation
of a larger sample of patients (Kassean & Jagoo,
2005).
The second study discussed a quality
improvement activity named as "Transform Care
International Journal of Caring Sciences September - December 2013 Vol 6 Issue 3
at the Bedside", organized by Chaboyer et al.
(2009) in Australia, giving special attention to
patient-centered aspect. A change from verbal
reporting in a room to bedside applied and for
this reason practice guidelines and a competency
standard were developed for the new handover
method. Six months after the implementation of
the change, patients’ and nurses’ perceptions
about the bedside handovers’ process were
positive (Chaboyer et al, 2009). Moving from
office to bedside handover the benefit was
double: reduction of handover’s time, as well as
reduction of incidents’ number frequency from
18 to 7 (Bradley & Mott, 2012).
A model for successful change from taped and
verbal to bedside handovers is proposed by
McMurray and colleagues (2010) in their
qualitative research paper, which was carried out
in two australian regional hospitals. In this
model, the authors examined every out of the 8
steps of the change management process. As it
was emerged from the findings, five themes were
important for the change: being part of the big
picture, linking the project to standardization
initiatives, providing reassurance on safety and
quality, smoothing out logistical difficulties and
learning to listen. Moving from the office to the
bedside, patients receive greater transparency,
accuracy accountability and communication
content appropriateness for their care plan
(McMurray et al, 2010).
To achieve the handovers’ change the support of
nursing administrators to the clinical nurses is
imperative. In a handovers’ improvement project,
almost half of the nurses’ population (60%)
considered support facilitation for the change
(Chaboyer et al, 2009).
Theme 3: Handovers’ standardization
Six studies were involved in handovers’
standardization process. To improve shift-to-shift
clinical handovers, a standardized operating
protocol (SOP) and minimum dataset (MDS),
given the acronym "HAND ME AN ISOBAR"
was developed. Each of the letters’ acronym
symbolized an action that guided the nurse for
the handovers’ performance. This was a four step
evidence-based focused approach and a
standardization solution, which adaption’s to
local circumstances/clinical areas (general
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310
medicine, general surgery, emergency medicine)
was flexible (Yee et al, 2009).
An observation of 532 handovers had been done
by Chaboyer et al. (2010). Handover content was
formalized by SBAR (situation, background,
assessment, recommendations), which comprises
a standardized format. Nurses believed that
bedside handovers offered promotion of patientcentered care, accuracy and service delivery
improvement.
Another qualitative research paper conducted in
multiple
specialty
settings
(general
medical/surgical, mental health, emergency, aged
care, critical care, maternity) highlighted the
specifity of every ward. The authors designed a
minimum data set for electronic nursing
handovers. The location and the content of
handovers were mentioned above. The Nursing
Handover Minimum Data Set (NH-MDS) is a
structured electronic tool and can guide nurses to
the direction of a comprehensive account of
patients’ condition and care in written pre-printed
summary format to complement verbal
handovers. The NH-MDS can be used in practice
and education by managers, clinicians and
educators, too (Johnson et al, 2012a).
Another study conducted by the same authors
and published the same year (Johnson et al,
2012b), examined factors (ICCCO) for the
purpose of support an electronic tool (digital
recorded handover data) and covers the range of
the critical patient information. Alongside, every
patient detail can be recalled from the staff at any
time, guidance to nurses and prioritization of care
are also available (Johnson et al, 2012b).
It is useful to remember that planning to
implement changes in a basic function of clinical
practice like handovers; a fundamental activity is
to provide feedback to nurses about its outcomes
(Chaboyer et al, 2009). Equally important is to
overcome standardizations’ barriers like the
difference in communication needs across the
wards that probably arise (Mayor et al, 2012).
Discussion
The nature of handovers is a direct reflection of
the nature of nursing shift and the value of
nursing interventions. Documentation of the
nursing process is a fundamental function of the
clinical practice (Ammenwerth et al, 2001).
International Journal of Caring Sciences September - December 2013 Vol 6 Issue 3
Handovers have a role of code, a channel of
communication among nurses, no matter the type
of clinic they are working in. The principal
function of handovers is the documentation of
information
around
the
nursing
care
(interventions and therapy steps) that has been
applied to the previous shift, the organization and
the preparation of the care that will be delivered
to the patients in the oncoming shift.
The well-structured handovers are reflecting a
fairly satisfactory level of the health services
offered by nurses. The quality and the accuracy
of the information that nurses handed over
protect and foster patient safety. However, in a
busy nursing shift nurses rarely engaged with the
documentation of patients’ care, especially when
nursing shortage is dominant. For this reason, the
contribution of a senior nurse practitioner to
ensure patient care quality by updating every
detail for patients’ progress in the available
documents is unique (Sexton et al, 2004).
The "perfect" or "good" or "successful" handover
is deemed the one without conflicting aims,
which is stating clearly the values that are
intended to be achieved by nurses (Meissner et
al, 2007). It should not be forgotten that there is
lack of guidelines on how to perform a nursing
shift handover.
The choice of the proper place (bedside or office)
and the way of handovers depends on a plenty of
factors. Every choice has its advantages and
disadvantages and some of them are documented
in the nursing literature. Taking for example the
ward environment, which is usually busy and
high demanding, is a factor that affects
significant components of handovers. A positive
correlation between handovers smoothness and
interruptions is mentioned in few studies
(Meissner et al, 2007, Evans et al, 2008, Liu et al,
2012). Interruptions during handover process
disrupt its course and this factor may be
responsible for nurses’ dissatisfaction with
handovers.
Across the countries, handovers’ categorization
and content presents variation. It is noteworthy
that nearly all studies mentioned in the
subcategory ′patterns/structure′ of the theme 1,
originated partly from emergency area settings
(Bruce & Suserud, 2005, Jenkin et al, 2007,
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311
Randell et al, 2011). Handovers’ content has to
do with the use of jargon, stereotyped phrases,
the communication of information of care or
sensitive information, non-verbal communication
ways and psychosocial subjects.
In the period 2005-2012, there have been
published many research papers examined steps
to the change of handovers’ type or their
standardization (Kassean & Jagoo, 2005,
Chaboyer et al, 2009, Yee et al, 2009, Chaboyer
et al, 2010, McMurray et al, 2010, Mayor et al,
2012, Johnson et al, 2012a, Johnson et al,
2012b). The process of change or standardization
of a handover needs to be done in a thoughtful
and well designed context. Results of the above
studies indicated positive evidence with valuable
data. But, it is fruitful to know the applicability
of them in different hospital settings.
Methodological issues of studies
Purely qualitative design (grounded theory or
ethnography) and methods (interviews or
observation or content/thematic analysis) were
the most predominant choices in many studies
(Payne et al, 2000, Sexton et al, 2004, Bruce &
Suserud, 2005, Philpin, 2006, McMurray et al,
2010, Johnson et al, 2012a, Randell et al, 2011,
Johnson et al, 2012b, Liu et al, 2012), as well as
mixed-method approach (Kerr, 2002, Yee et al,
2009, Chaboyer et al, 2010, Bradley & Mott,
2012, Mayor et al, 2012).
Researchers used as sample for their studies the
observation of handovers conducted in wards
(Kerr, 2002, Sexton et al, 2004, Evans et al,
2008, Randell et al, 2011, Johnson et al, 2012a,
Johnson et al, 2012b), staff members/patients
(Bruce & Suserud 2005, Jenkin et al, 2007,
Meissner et al, 2007, Chaboyer et al, 2009,
Bradley & Mott, 2012, Liu et al, 2012) or both
(Payne et al, 2000, Kassean & Jagoo, 2005, Yee
et al, 2009, McMurray et al, 2010, Chaboyer et
al, 2010). In one study, there were used
documents plus the sample of nurses (Philpin,
2006). The sample size or the observation of
handovers derived from multiple hospital wards
(Payne et al, 2000, Kerr, 2002, Meissner et al,
2007, Chaboyer et al, 2009, Yee et al, 2009,
Chaboyer et al, 2010, McMurray et al, 2010,
Randell et al, 2011, Bradley & Mott, 2012,
Johnson et al, 2012a, Johnson et al, 2012b).
International Journal of Caring Sciences September - December 2013 Vol 6 Issue 3
Limitations
There are several limitations to this study that
have to be mentioned. Firstly, there were
methodological limitations. The search has been
done in only one database and conclude papers in
english, published after 2000 with free provision
of full text. The last two factors may set out of
the search several studies. Then, the analysis of
the evidence found, was done by one author.
Secondly, there were studies like this of Yee et
al.
(2009),
whose
transferability
and
generalisability of their outcomes need further
consideration.
Relevance to nursing education, clinical
practice and implications for further research
Benefits of this review concern nursing
education, research and clinical practice. In the
first level, strengthening the basic nursing
knowledge by the incorporation of the required
knowledge for standard practices like handovers,
in nursing education programs remains a
challenge. Nursing students need to be informed
about, to comprehend and able to apply this
communication process, when they will work in
the ward environment as qualified registered
nurses.
Concerning the clinical nursing practice,
handovers help nurses to shape professional
identity (Payne et al, 2000). The development of
concise guidelines is beneficial for the
standardization to devote more time to direct
patient care (Sexton et al, 2004). Also, suitable
leader nurses had a substantial role in the
handovers’ quality improvement (Meissner et al,
2007).
Since nursing shift handovers represent a pivotal
function which is implemented by nurses in
everyday practice, important dimensions for
further research and debate could be the:

theme of structured or not handovers
(Sexton et al, 2004)

assessment of the multidisciplinary team
contribution in the handovers’ function
(Kassean & Jagoo, 2005)

development of guidelines or a formal
handover sheet would be useful to guide for
nurses to carrying out the handover process
(Pothier et al, 2005, Jenkin et al, 2007)
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312

integration and teaching of handovers in
nursing education (Jenkin et al, 2007)

patients’ interaction during handovers
(Johnson et al, 2012b).
In line with the above goals, when studying
nursing handovers issues or when handovers are
under redesign or reassessment, it is useful to
evaluate further the factor of uncertainty (Mayor
et al, 2012).
Conclusion
This review paper provided some insights into
the research evidence of approximately the last
decade,
examining
fundamental
issues
concerning handovers in nursing, a considerable
topic of communication. Nursing handovers are
an integral function of the clinical nursing
practice and all nurses should have detailed
knowledge about the piece of information which
synthesizes this procedure. By improving
handover practices, patient safety is enhancing as
well. Finally, nursing shift handovers and their
constant improvement should be high priority
issues for clinical nurses.
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